Chapter 21: The Development of the Medical Student

Chapter 21: The Development of the Medical Student

Howard S. Becker et al. in Boys in White: Student Culture in Medical School (2002)

We began our study with a concern about what happens to medical students as they move through medical school. This concern receded as we became more and more preoccupied with what went on in the school itself and, particularly, with the problem of the level and direction of academic effort of medical students. Nevertheless, there are some things we can say about how medical students change and develop as they go through school.

There are two views commonly held concerning what happens to students as a result of their schooling. One is that they are socialized into a professional role. Mary Jean Huntington has shown that medical students are more likely, with each succeeding year in school, to say that they thought of themselves as a doctor rather than as a student on the occasion of their last contact with a patient. She interprets this to mean that medical students gradually develop a professional self-image in the course of their medical training. Similarly, Renée Fox has analyzed the development of the medical student as a process of learning and assimilating the traits the student will need in order properly to play the role of physician once he has left school. For instance, she argues that students get a thorough training in dealing with the many areas of uncertainty they will have to face as physicians and that medical schools, whether purposely or not, are organized to make sure that students get that training. Training for uncertainty is only one of the kinds of training students get in preparation for their future professional role, in Fox’s view. Other areas of such training are detached concern, time allocation, and so on.

We have not found this framework useful in analyzing our data on the Kansas medical student. We have already seen in earlier chapters that the Kansas students do not take on a professional role while they are students, largely because the system they operate does not allow them to do so. They are not doctors, and the recurrent experiences of being denied responsibility make it perfectly clear to them that they are not. Though they may occasionally, in fantasy, play at being doctors, they never mistake their fantasies for the fact, for they know that until they have graduated and are licensed they will not be allowed to act as doctors.

We have explained earlier why we felt it not fruitful to think of the student’s training as providing him with the attitudes and values necessary for professional practice. We do not feel that we know what attitudes and values will help the student adjust most easily and adequately to the professional role he is going to play, for we do not know what that role consists of. Furthermore, the argument that certain things are learned latently which will have an effect on the student’s behavior in the distant future strikes us as quite speculative.

A second, and extremely common, view of the development of the medical student is one that stems from lay concern with medical practice but has been investigated by social scientists. This is the view that one of the important effects of medical school is to make the student considerably more cynical than he was when he entered. Laymen and medical educators alike are inclined to accept this as obvious; indeed, attitude studies seem to support this view. Our data suggest that this oversimplifies a complex process. The term cynicism and its antonym idealism are used loosely. They require more specific definition.

People ordinarily think of cynicism and idealism as general traits of persons. The cynic so conceived is a man who has no belief in the ultimate worth of what he is doing and no interest in doing good to others; the idealist, a man who thinks his work worthwhile and who wants to help others. According to this view, these attitudes inform every area of a man’s thought and activity. It is more likely that these are not general traits but ways of looking at people and situations. Consequently, they vary according to the person or situation one is looking at. A student may be cynical about some things but quite idealistic about others. Those studies in which students’ “cynical” attitudes are measured by asking them to agree or disagree with general statements about human nature (such as: “Most people are out for what they can get”) obscure this point by not taking account of the specific referents of the attitude. A person’s attitude may be cynical or not, depending upon the audience to whom he is interpreting his actions. He may speak cynically to an audience of his peers but idealistically to an audience of laymen, or he may do the reverse. We should recognize that cynicism and idealism are not general attributes of the actor, but judgments made by either the actor or someone else about his activity and feelings in certain circumstances. No act or attitude is in itself cynical or idealistic. It depends upon the situation and how one looks on it. Many things may appear cynical to laymen which would appear neutral or even idealistic to medical students or practicing physicians.

Two sets of ideas characteristic of medical students seem particularly cynical to other people. As a result of their experience in school students acquire a point of view and terminology of a technical kind, which allow them to talk and think about patients and diseases in a way quite different from the layman. They look upon death and disabling disease, not with the horror and sense of tragedy the layman finds appropriate, but as problems in medical responsibility. The technical attitude which prevents the student from becoming emotionally involved in the tragedy of patients’ diseases seems to the layman cruel, heartless, and cynical.

In a more sophisticated way, some observers (in this case not only laymen) but also members of the medical faculty) think students cynical because they set for themselves some standard of a reasonable and proper level of effort. When, for instance, members of the faculty complain about the “eight to five” student, they are complaining that students do not make as complete an effort as might be made. Similarly, our finding that freshmen decide it is necessary to select some of the material they are presented with for intensive study while ignoring other material will seem to some people an unjustifiably cynical approach to the study of medicine.

Where the immediate situation of the student dictates the development of a perspective of the kind we analyzed in our consideration of student culture, the layman is likely to see the development of grained, long-lasting cynicism. While this would be a misreading of our analysis, the problem warrants our making a more differentiated analysis, using a dimension of which cynicism and idealism are points, of what happens to students as they move through medical school. We shall point out both the ways in which students become “cynical” in the layman’s view and the ways in which, looked at from other vantage points, students may be said to be continuingly idealistic.

We believe that medical students enter medical school idealistic about the practice of medicine and the medical profession. They do not lose this idealistic long-range perspective but realistically develop a “cynical” concern with the day-to-day details of getting through medical school. As they approach the end of school they again openly exhibit an idealistic concern with problems of practice. In other words, the students simultaneously maintain an idealistic view of the broader problems of medical practice, a view which has its roots in lay culture, and a narrower view which sees the only important problems as those posed by the daily exigencies of school itself. This relation between what we might refer to as extra and intramural interests occupies our attention for the rest of this chapter. The process we describe may be easily generalized to other institutions and thus have a sociological significance beyond the case under consideration.

We have already seen that medical students enter school with broad and idealistic concerns. They are not interested in medicine as a way of getting rich; this may be because they feel so sure of doing well financially in medicine. In any case, income is not a major concern of students when they enter school. They come in with a complement of ideas about healing the sick and rendering service to mankind. They resent any hints that they may have crasser motives. They are determined to learn all the facts that the medical school will give them, in order that they may do the best possible job of caring for the patients they will later have. They work long hours and are willing to work even longer ones.

These idealistic notions have little relevance to the students’ activities in medical school. The work they do in the first year appears to them far removed from anything having to do with sick patients and, besides, there is so much of it that they cannot possibly learn everything as they had expected to do. No matter how hard they work, they are told by the faculty, and believe, they will not be able to learn it all. This being the case, they must decide which of the many facts they are brought into contact with they will try to remember and make use of. For awhile, some students try to make this choice by thinking ahead to their prospective medical practices and seeing what will be most needed there. But they really know nothing of what will be needed in medical practice so that this is not a workable criterion.

What is much more pressing is their discovery that they must first of all pass the examinations set for them by the faculty; if they do not they will not practice medicine at all. Though the examinations sometimes appear unrelated to the problems of medical practice and arbitrary, they are still facts of life with which the students must deal. So the students, some quickly and others more reluctantly, take the view that the way to get through the first year of school is to find out what the faculty wants them to know and learn it. This concerns them deeply, for it seems to them a violation of the idealistic notions with which they entered their training. But they find it absolutely necessary to concentrate on learning in order to get through school and to give up their idealistic concern with learning in order to alleviate suffering. In the course of the upsets caused by the examinations of the first year, the students engage in increased communication across lines that formerly divided them, so that by the end of the year the entire class is united on the basic proposition that the important thing is to get through school.

It is this immediate concern with getting through school that appears cynical to many outside observers. Students do not worry much about the fact of death; they are not very much bothered by the fact that the cadavers they now dissect were once living human beings. A cadaver is primarily a device for acquiring certain facts they may be asked for on an examination. They have little time for concern with what kind of a person the cadaver once was. Successful students put such questions aside.

With the advent of the clinical years, students’ concerns become more closely entangled with the fate of living patients. But here again, the pressures of school are so great that they take first place in the students’ minds. Students become engrossed with the problem of “working” faculty and house staff for as many nuggets of clinical experience and as many opportunities to exercise medical responsibility as possible. They worry about always presenting a good front to their superiors and never making a bad impression. They organize to share their collective work more equitably and to prevent situations in which one student will make the others look bad by working too hard. Students do these things because they are so earnest about using their time in school to acquire the knowledge and experience they think they will need in practice, and because they want to graduate and be licensed to practice. They see many of the requirements faculty make as interfering with their pursuit of knowledge by encumbering them with “busy work”; students’ dislike of doing admission laboratory work on patients, for instance, falls in this category.

Again, these concerns make students appear cynical to an outside observer. As we have seen, students are not concerned with their patients in terms that are found in lay or medical culture. Instead they tend to view patients in terms that are adapted from student

culture, terms that reflect their concern with doing well as students. For instance, a patient who dies reminds them less of medicine’s tragic inability to control disease than of the autopsy they will have to attend. From the students’ point of view, the autopsy is a procedure which will take a great deal of their time and from which they will get information they might acquire more quickly from the pathologist’s report. At the same time, they will also have to prepare an autopsy report which may, if it is not done properly, make a bad

impression on the faculty. The requirements of their immediate situation force these practical considerations on them. This attention to short-run considerations in situations containing tragic elements is the kind of student behavior that dismays laymen, although to students it seems reasonable and necessary.

The medical student in his fourth year thus appears to the outsider as a pretty tough and cynical customer. But toward the end of that year, as he approaches graduation, he reveals that medical school has had some other effects on him. His concern with getting through school becomes inappropriate, for he is now almost through school (Though he may still fear that he will not graduate, he really knows that this is irrational and that the chance of his not graduating is very slim.) He begins to look ahead, beyond medical school, to internship and practice. He knows that in these situations one does not worry about impressing a faculty member, but about taking care of one’s patients as best one can while living the life of a physician in a community. He thinks about the many problems he will face and the many pressures he will be subjected to and wonders how he will behave when he meets the realities of medical practice. The question of how he will be able to do his best for those he serves occupies his mind and he finds no ready answers. In short, he loses his concern with the immediate situational problems of medical school and once again openly exhibits those broad concerns with service to humanity that. characterized him as an entering freshman.

The medical student is now idealistic with a difference. His idealism is more informed and knowledgeable, for he has learned a lot about what to expect and fear in medical practice. He has picked up some ideas about how one can overcome some of the problems to be faced. His idealism is more specific and more professional than it was when he entered. The layman, not seeing things the way the student does, or indeed the way the doctor does, may miss the idealistic content of much of these student concerns. From the medical point of view, however, this idealism is evident.

We believe that this new idealism is simply a more informed version of the idealism with which the students entered. That idealism, however, is inappropriate to the facts of life in school, so the student becomes concerned with those things which are important while he is in school. He does not evaluate school matters in broad idealistic terms because those terms are not relevant. But when he is asked to think about the future, about things beyond school, his idealism reveals itself and when he approaches the end of school it bursts into full bloom.

Our evidence for the existence of this late-blooming idealism is necessarily indirect. We asked students no questions having immediate reference to this problem. But the character of students’ perspectives on their medical futures, coupled with scanty but telling incidents from our field work and answers to certain subsidiary questions in the interview provide a solid base for the proposition that students leave school in as idealistic a mood as they entered.

One excellent indication of the continuing, though underground, existence of student idealism is found in the criteria they use to evaluate specialties. We saw in the last chapter that the most frequently used criterion is that of intellectual breadth. This came as a surprise

to us, for it is not something that is often mentioned in student discussions of school and schoolwork. But when they are able to think beyond school to the future this criterion comes up more frequently than any other. It is a criterion which assigns maximum importance to knowing all there is to know, in order that one may treat his patients more effectively. The use of this idealistic criterion with reference to the future recalls strongly the freshman insistence on learning everything the school has to teach. On the other hand, such crass criteria as income and the number of hours one puts in a specialty play a relatively unimportant part in student evaluations.

Another evidence of student idealism we have already seen is the manner in which certain students, toward the end of their undergraduate medical education, begin to think about specializing. They do this, not because they seek greener pastures in a specialty practice, but because they feel that this is the only way in which they will be able to do justice to their patients. They think of a general practice as requiring so much knowledge and so much skill that one man cannot possibly handle it adequately; therefore, they reason, the only honorable thing for them to do is to become more skilled in some one branch of medicine so that they may thereby hope to give their patients the best possible medical care. It should be remembered that in doing this students think of a general practice as one that will be quite rewarding financially, perhaps not quite so much as a specialty practice, but enough so that the extra years of training are not warranted in view of the financial sacrifice involved in taking a residency.

Underlying idealism among students can be found in the standards they say they intend to apply when they set up their own practice. For example, many students volunteered the information that they hoped never to treat a patient without first establishing a diagnosis. This is an ideal the faculty preached to them, but one which is sometimes honored more in the breach than in practice by practicing physicians. Many diagnoses are difficult to make and the average practitioner often cannot afford the time (or perhaps his patient cannot afford the expense of the necessary tests) to live up to this high standard. Yet students matter-of-factly state that they intend to operate their practices in this way, with all that this implies about reduced income (because one necessarily sees fewer patients) and increased difficulty and strain. The following conversation illustrates the kind of observation which led us to see the students’ insistence on establishing a diagnosis as an idealistic attitude:

Perkins told a story about an OB man at a local hospital. He said this doctor had operated on a young girl for a fibroid tumor but had discovered, on opening her up, a five-month-old fetus. He said, “I guess she lied to him and said she wasn’t pregnant and he didn’t think of it because she wasn’t married. But he didn’t know a thing about it. He didn’t even try to make a diagnosis. The thing was that he could have done a Friedman test on her and found out if she was pregnant first, but he didn’t do it. After all, when you have a mass in the abdomen of a twenty-seven-year-old woman the first thing you have to rule out is pregnancy. Then you start thinking about fibroids and carcinomas and things like that. But the first thing is pregnancy. I even saw the chart. The extern who worked her up was just a junior medical student. He put right down on the chart, ‘Rule out pregnancy,’ and they never did a thing about it.”

One of the other students suggested this might have been an honest mistake. Perkins said, “Maybe he was honest but that isn’t the right way to practice medicine. After all, the big thing in medicine is to make the right diagnosis. Any clunk can carry out the treatment once you know what the trouble is.”

(Senior Surgical Specialties. October, 1956.)

Closely related to this is another evidence of student idealism. We asked them how many patients they expected to see in a day when they had established their practices. This question was suggested to us by student comments on their preceptorships. Many students expressed great concern over the number of patients the G.P.s they worked with saw in a day and could not see how one could give adequate medical service when seeing that many patients. If each patient gets a complete diagnostic work-up and treatment is not attempted without a firm diagnosis, it follows that the doctor must spend more time with each patient and simply cannot see seventy or eighty or one hundred patients in a day. He must reduce his patient load considerably. Students typically expressed concern about this problem and thought much about what could be done about it. For example:

“That’s another thing that worries me about general practice – this business of seeing seventy or eighty patients a day. I know a lot of those fellows do it and I don’t know how they do it. That means you would spend more than seven or eight minutes with each patient Why, you’d hardly get to say hello and goodbye in that time. I just can’t imagine how anyone carried on a practice like that. Of course, I suppose a lot of the patients you’d see that way wouldn’t really have anything wrong with them and wouldn’t need anything but to have their prescription refilled or dressing changed or something like that. But even so, it must be awfully hard – I don’t see how they do it. I don’t think I could, but I don’t see how I could turn them away either, so that’s one of the things that makes me kind of shy of general practice.”

(Senior Surgical Specialties. September, 1956. )

Many students, when asked how many patients they expected see in a day, arrived at their answer by figuring out how long it would take to give each patient a complete work-up and how many hours they could work efficiently in a day. Typically they hoped to be able to limit themselves to a relatively small number of patients: 60 percent of our interviewees said they expected to see no more than twenty-five a day; another 20 per cent could not give any figure; only 20 per cent expected to see more than twenty-five per day. The heavy preponderance of students who wanted to keep small the number of patients they saw indicates that the idealistic problem of providing the best possible care for patients was a major concern.

This conclusion is strengthened by the explanations students when we asked them to explain the basis on which they had made their estimate of the number of patients they would see. Twenty-eight of the sixty-two students interviewed gave no reason, but twenty-one said they had chosen the number they did because one could not treat any more patients than that and still do a good job. The other explanations consisted of caveats pointing out that any number mentioned would be arbitrary, since the number of patients one saw would depend on such variables as the kind of specialty one was in, the cases one saw, and the success of one’s practice. One student suggested that the number might not be up to the physician who, if he were the only doctor in a given area, would have to see everyone who came to no matter how many there were.

Among the possibilities that students see for dealing with this problem of the number of patients is some form of group practice. Students believe that if one associates himself with several other physicians will be able more easily to control his own workload and thus do a better job. While it is true that some of the concern for group stems from a desire to avoid the rigors of solo practice, it is still true that many students see it as a way of providing better medical care.

Students’ views of their future careers frequently refer, as we have seen, to the dilemma of independence versus responsibility. Should one immediately become a full-fledged independent practitioner or is it better to arrange one’s practice so that one has older (and, perhaps, more experienced) colleagues who can share the heavy burden of medical responsibility? To see such a dilemma at all implies a real concern for the welfare of one’s patients which must be interpreted as idealistic.

When we asked students, “What is your idea of a successful physician?” the answers again revealed the presence of long-range idealistic views. We supposed that this question would be likely to provoke materialistic answers: references to large incomes, large houses, and large cars. We erred in making this assumption, for 87 per cent of our sixty-two interviewees gave answers that could only be categorized as idealistic. They typically spoke of the successful doctor as one who really helped his patients, as a man who had worked hard and acquired all the skill and knowledge necessary to give such help. Many students, of course, also mentioned a large income or a large practice, but only 13 per cent failed to give any kind of an idealistic answer. We further find support for our contention that students never lose their idealism but simply find it irrelevant to their daily concerns in school in the fact that, looking to the future as they do in answering this question, the percentage of students giving idealistic answers does not change much from year to year. Only among the sophomores does it fan to 64 per cent; 93 per cent of the seniors, 95 per cent of the freshmen, and 93 per cent of the juniors give idealistic answers (see Table XLV).

Finally, we may interpret as expressions of student idealism answers to the following question, asked in our student interviews: “Would you like to practice in a hospital or community where everything you do is reviewed by a committee of other physicians?” Of the sixty-two students questioned, thirty-five (or 56.5%) answered “Yes.” Only twenty-two (or 35.5%) did not like the idea; five students (or 8%) said it made no difference, or that it might be a good idea, or that they did not know. In other words, better than half of the students gave unqualified support to this idealistic idea. Furthermore, although the reasons given for the “No” answers can be interpreted as rationalizations, and the true motive behind the answer ascribed to fear of being found out in inadequate practice or some similarly low motive, these reasons express idealism too, though in a different way. The most frequent reason given against the notion of having physicians’ work reviewed was that it would frighten the doctor so that he would not take some of the chances it is necessary for a physician to take if he is to practice adequately and give his patients the best possible care.

All of these signs indicate that students maintain their idealism throughout school, even though they do not apply it to the immediate situations of school life. When they leave medical school it comes to the fore, but it now has a more specific character, consisting of concrete ideas about how certain problems of medical practice to be faced. Those who fear that medical students leave school too cynical should take heart from the students’ interest and concern over such problems as treatment on the basis of a firm diagnosis, the number of patients one should see, and so on.

This analysis of medical students’ idealism and cynicism may have a certain general relevance. Sociologists often speak of the way generalized values influence behavior through a variety of situations. There is no doubt a great deal to this contention, but our findings from the medical school indicate that this is not all of the story. To put these in more general form, we may first of all note that the proposition that values influence behavior is insufficient; it is equally true that situations influence values. When the medical students find the idealistic values they bring from their lay backgrounds irrelevant and not applicable in the medical school situation, they use others which have more immediate bearing while maintaining their idealistic values for situations in which they will be more appropriate.

In short, people find it possible to maintain two sets of values, between which there are possible contradictions and incompatibilities, at the same time. Immediate situational pressures constrain behavior in the present and play an important part in shaping the values participants make use of. But this influence need not have any effect beyond the situation in which it operates. Values operate and influence behavior in situations in which they seem to the actors to be relevant. Where that relevance is not clear, the values are not used and others, more appropriate to the problems to be faced, are brought into play. But this does not mean that the original values are gone forever. Instead, these values may simply lie dormant, ready to be made use of as soon as an appropriate situation presents itself.

Recognizing this relation of values to situations allows us to be more specific about the relations between immediate and long-range perspectives. Long-range perspectives are diffuse and generalized and do not state specific imperatives to be followed under specific conditions. Rather, they suggest a mood in which one will approach specific situations and generalized values one will try to maximize. But the immediate situations in which action must be taken constrain behavior in specific ways and actors must come to terms with these immediate situational imperatives. The patterns of thought and action they develop in meeting these imperatives are their immediate perspectives. Long-range perspectives influence actors’ behavior in immediate situations insofar as they are seen by the actors as relevant and possible to use. Where the long-range perspective appears to be irrelevant to the situation at hand or impossible to make use of under the circumstances, it will have no influence on immediate perspectives. Nevertheless, actors may continue to hold their long-range perspective, using it to think about future situations whose situational constraints they are not aware of.

The experience of medical students suggests a process which may operate in many arenas of life. It is frequently the case that people are taken out of the main stream of ordinary life to participate in a somewhat enclosed and isolated institution for a more or less specified period of time. Such participation in isolated institutions is frequently, though not always, brought about for the purpose of effecting some change in the attitude, values, and behavior of those who participate. In addition to schools of all kinds, prisons and mental hospitals immediately come to mind as examples of such institutional participation.

Medical students come to medical school in order to be changed. They willingly submit to a long ordeal in order to come out of it something different from what they went in. Even in this case, however, where the desire of participants to be changed is so high, we find that the effects of institutional participation are quite complicated. Going to medical school does have an effect on students, but this effect is not a simple one. Students do not simply become what the medical school wants them to become. Indeed, their own broad and idealistic notions about what they ought to become are pushed aside as they turn their concern to the immediate business of getting through school. To be sure, they attempt throughout to make use of the school to further these idealistic ends, but this is neither a fruitful nor a rewarding procedure. So they become “institutionalized.” That is, they become engrossed in matters which are of interest only within the school and have no relevance outside it. When their participation in the school ends, they give up these concerns, realizing that they are no longer of any value.

Nevertheless, participation in the school has had some effect, for the long-range perspective that students brought with them has remained and been transformed by the school experience, being made more professional and specific. There is enough congruence between their long-range perspectives and the immediate perspectives they develop in response to the problems school sets for them to allow this kind of transformation to take place. Pedagogically speaking, the worst situation would be that in which there was such disparity between the students’ long-range perspective and the immediate perspectives enforced by the situation that no such transformation could take place. In the medical school we studied the situation probably approaches the optimum, for the immediate perspectives students acquire in school have an effect of the kind the faculty desires on their long-range perspectives.

Nevertheless, it is quite possible that this effect does not last once the young physician enters practice, or that it persists only if the immediate situation of practice is one to which the values contained in the long-range perspective seem appropriate. Just as students make use of values which appear appropriate to their situation in school, the practicing physician will use those values which seem appropriate to the situation he is practicing in. A recent study of general practitioners in North Carolina shows that many of them do not persist in the habit of making extensive and thorough examinations of patients they presumably acquired in school. Furthermore, after the physician has been out of his school a decade, variations in the thoroughness of the examination are not related to such variables as the school he attended or his rank in the graduating class. This suggests the validity of our view that values learned in school persist only when the immediate situation makes their use appropriate.

A recent study of a prison suggests that a similar relation between immediate and long-range perspectives can be found in such institutions as well. Prisoners come in desiring to be rehabilitated and exhibiting substantial attachment to law-abiding values. But once in prison they become concerned with achieving prestige and power within the prison walls and one of the ways of doing this is to drop one’s concern with rehabilitation and “going straight.” This adjustment to prison folkways is temporary, however, and the nearer convicts come to completing their sentence the more likely they are to drop their interest in prison affairs and once more concern themselves with the possibility of a life within the law.

It is quite possible that such processes occur in many other settings. We think it likely, for instance, that the experience of attending an undergraduate college has precisely this character for many students.

Discussion Questions

  1. Would you agree with the authors? Are medical students today more cynical or idealistic towards the profession? What leads to the development of these attitudes?
  2. How do medical students evolve in the degree of their cynicism/idealism over the course of their journey through medical school, residency, and practice?

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